Healthcare Provider Details

I. General information

NPI: 1245064245
Provider Name (Legal Business Name): WEST COAST INDIVIDUAL AND FAMILY THERAPY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2024
Last Update Date: 08/30/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10061 TALBERT AVE SUITE 200/365
FOUNTAIN VALLEY CA
92708
US

IV. Provider business mailing address

2709 SOUTH DIAMOND STREET
SANTA ANA CA
92704
US

V. Phone/Fax

Practice location:
  • Phone: 714-222-3864
  • Fax: 714-963-4703
Mailing address:
  • Phone: 714-222-3864
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: MR. MARK RAYMOND GERY
Title or Position: OWNER
Credential: LMFT
Phone: 714-222-3864